Basic Information
| Provider Information | |||||||||
| NPI: | 1801068309 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOW COUNTRY MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 S MAIN ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | HINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313134354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128776822 | ||||||||
| FaxNumber: | 9124086781 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 S MAIN ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | HINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313134354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128776822 | ||||||||
| FaxNumber: | 9124086781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2008 | ||||||||
| LastUpdateDate: | 03/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | RUFF | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9128776822 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.